Provider Demographics
NPI:1508008871
Name:LODGE, LORI (LCPC LMFT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:LCPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2971 E COPPER POINT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5101
Mailing Address - Country:US
Mailing Address - Phone:208-376-5683
Mailing Address - Fax:208-376-5690
Practice Address - Street 1:2971 E COPPER POINT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5101
Practice Address - Country:US
Practice Address - Phone:208-376-5683
Practice Address - Fax:208-376-5690
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2907101YP2500X
ID2929106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist